Provider Demographics
NPI:1871386961
Name:FULLER, CARL JR (LMSW)
Entity type:Individual
Prefix:MR
First Name:CARL
Middle Name:
Last Name:FULLER
Suffix:JR
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1869 E 17TH ST
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74104-5304
Mailing Address - Country:US
Mailing Address - Phone:405-549-4356
Mailing Address - Fax:
Practice Address - Street 1:1869 E 17TH ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74104-5304
Practice Address - Country:US
Practice Address - Phone:405-549-4356
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-22
Last Update Date:2025-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK20646104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker